Gap Cover FAQ’s

GAP COVER

Why is it important to have gap cover?

Gap cover products are designed to cover medical expense shortfalls that exist between the fees charged for private healthcare and what your medical scheme pays. Being covered by Stratum Benefits leaves you feeling assured that when you become liable to pay a portion of your service providers’ accounts, the unexpected difference won’t leave you out of pocket.

Our product offering boasts an array of additional benefits that cover you when you are required to settle an upfront co-payment, or when having to pay a portion towards your service providers’ account for your oncology treatment, internal prosthesis, MRI or CT scans, casualty events or trauma counselling to name but a few.

Who qualifies for gap cover?

Gap Cover covers you and your loved ones when you belong to a registered South African medical scheme. Our products are compatible with all medical schemes; providing cover to individuals and families as well as corporate employer groups.

Who is covered on a gap cover policy?

Members registered on your, your spouse’s or your children who may be registered on your ex-spouses medical aid can be a dependant on your Gap Cover policy, however, if you have an ex-spouse, even if they are registered on your medical aid as a dependant, they will need to be placed on their own gap cover policy.

The oldest and wisest insured person determines the monthly premium and therefore, where a dependant aged 65+ is added to your Gap Cover policy, your monthly policy premium will increase to the 65+ premium category applicable to your chosen option.

Besides our comprehensive Gap Cover Product Range, we also provide an essential Health Insurance Product Range for individuals from all walks of life. Individuals and corporate employer groups can choose between Day-To-Day Benefits, Emergency & Accidental Benefits or a combination option.

Will a guarantee of payment be issued to my service provider prior to my medical procedure or treatment?

Certain queries cannot be resolved without following an appropriate process or receiving necessary supporting documentation. Therefore we are unable to issue guarantees of payment for any of our Gap Cover product ranges, as several factors influence the outcome of a claim, such as your waiting periods, general exclusions, and the portion your medical scheme paid towards your service providers’ accounts.

If however you are wanting to claim against our Access Optimiser product, then provided the correct supporting documentation and process is followed, then a guarantee of payment may be sent to the applicable service provider.

What is OPL and how does this affect my Gap Cover?

An OPL is your Overall Policy Limit that either applies to each insured person per year or to each policy per year. This means that all benefits accumulate towards a policy limit of R 100 000 or R 157 000 per policy per year (Access Optimiser) or R 157000 per insured person per year, depending on the Gap Cover option you are covered on. It’s important to note that certain benefits have their own individual benefit limits and when combined, cannot exceed the Overall Policy Limit. Our Cancer Diagnosis Benefit, Premium Waiver and Accidental Death benefits do not accumulate towards the Overall Policy Limit.

Once you’ve reached the Overall Policy Limit applicable to your Gap Cover policy, you will not be able to claim against your policy for the remainder of the year, where the benefit is applicable to the OPL. Where the benefits do not conform to the OPL, you may claim against the benefits until the benefit limit is reached. Our policy renewals take place each year effective on the 01 January where you can then make use of your policy again. Your dependant(s) however will still have cover until such time that they reach their respective Overall Policy Limits

Will my new born baby get underwriting if I add them to my policy?

Your new bundle of joy, addition to your family will only receive full underwriting if they are not added to your Stratum Gap cover policy within the first 6 months of their birth. If you registered your baby as a dependant to your policy within 6 months of their birth, then no underwriting will be applied, provided the policy is out of the 3-month general waiting period. If the policy is still within the 3-month general waiting period the balance of the general waiting period will need to be carried out, however no pre-existing waiting periods will be applied to the baby.

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